Recently a family doc published a "Viewpoint" in the Journal of the American Medical Association suggesting restraint and caution in using the ACEs screening tool (Campbell TL. Viewpoint, Screening for Adverse Childhood Experiences (ACEs) in Primary Care: A Cautionary Note, JAMA Published Online: May 28, 2020, doi:10.1001/jama.2020.4365) because (1) there were no evidenced based treatments, (2) asking the questions would offend patients and parents, and (3) risk of labeling people with such exposures as high risk.
A good group of us (Jeoffry B. Gordon, MD, MPH, (Member, California Citizens Review Panel on Critical Incidents (child abuse fatalities), Charles B. Nemeroff, MD, PhD, (Matthew P. Nemeroff Professor and Chair, Department of Psychiatry and Behavioral Sciences, Mulva Clinic for the Neurosciences, Director, Institute of Early Life Adversity Research, Dell Medical School, The University of Texas at Austin, Vincent Felitti, MD, (Retired, Chairman, Preventive Medicine, Kaiser Permanente of San Diego), Randell Alexander MD PhD, (Professor and Chief, Division of Child Protection and Forensic Pediatrics, University of Florida – Jacksonville); Thomas Boat, MD (Professor of Pediatrics, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center); David L. Corwin, MD (Professor and Director of Forensic Services, Pediatrics Department, University of Utah School of Medicine, President, American Professional Society on the Abuse of Children); Drew Factor, MD, MPH (Independent Internist, member of the Trauma-Informed Practices Subcommittee, Essentials for Childhood Initiative Program, California Dept of Public Health); Pradeep Gidwani, MD, MPH, FAAP (Medical Director, Healthy Development Services and First 5 First Steps Home Visiting Services, American Academy of Pediatrics, California Chapter 3); Tasneem Ismailji MD, MPH (Co-founder and Board Member, Past President and Board Chair, Academy on Violence and Abuse); Richard Krugman, MD (Distinguished Professor of Pediatrics, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado Medical School); Martin T. Stein, MD (Professor of Pediatrics Emeritus, University of California San Diego) with extensive experience submitted a contrasting "Viewpoint" outlining all the reasons we found ACEs (and similar screening questionnaires) to be an important and underused clinical tool with lots of potential benefits.
I am writing to inform you all that the editors of JAMA did not find it worth their while or important enough to publish a rebuttal. It seems mainstream medical thought still is more than ignorant but is, in fact, positively ashamed, embarrassed and avoidant of the fact that child abuse is so common and has so much effect on health outcomes.
I encourage others who have the same frustrations, or who have similar experiences to share them here.
The substance of our reply to Campbell and JAMA is in the following 10 points:
- Child Abuse and neglect are epidemic in the United States. In multiple studies 20 to 25 per cent of the adult population has had a significant ACEs exposure. The effects of CAN impact a substantial number of our patients even while we physicians remain unaware.
- Campbell is correct CAN is not the disease. The physical and psychological adaptations to the trauma/stress of CAN contribute to pathology. (Think of the relation between cholesterol and coronary artery disease, acute anemia and syncope.)
- Campbell assesses the value of ACEs screening against the US Preventive Services Task Force’s recommendations on screening asymptomatic people for primary prevention. He misses the fact that most of the procedures assessed by them are applied to populations that have a prior predicted prevalence of 1 in 2,000 to 10,000. ACEs screening is not being recommended for primary prevention purposes, rather for “risk assessment” of patients, some of whom may have unidentified symptoms, to initiate intervention. In children before age 18 the population prevalence is at least 1 in 8, while among USA adults it is 1 in 4 to 5.
- Knowledge of CAN trauma through using ACEs screening can improve prevention and treatment of many other common existing physical diseases, e. g. obesity (This is how the ACEs paradigm was discovered), smoking/COPD, substance abuse.
- Identifying CAN trauma through ACEs screening can improve the prevention and treatment of many other mental illnesses. Like Dr. Campbell, contemporary psychiatry, through the DSM paradigm, defines CAN as “an environmental condition, not a disease” thus overlooking the contribution that the distinct psychological trauma of CAN contributes to many DSM defined diseases as a co-morbidity thus impairing research, prevention and treatment of those diseases.
- Without a doubt the sequelae of CAN as revealed by ACEs screening are a complex bio-psycho-social problem. Optimal treatment of this pathology in the clinic does not easily lend itself to a simple or quick pharmacologic or technologic remedy. Thus while it inevitably may put stress on the busy clinical practice this problem does evoke the caring and compassion at the heart of medicine and competent specialized interdisciplinary resources are available across the country to provide support to primary care clinicians.
- Campbell makes an important observation when he observes, “No interventions have been shown to improve outcomes for children or adults who report a high number of ACEs.” Screening for and compassionate, nonjudgmental listening to patients talk about their ACEs is the first healing modality. Child abuse specialists have explicitly remarked “child abuse and neglect has been relatively ignored (by the major sources of federal research funding)….As a result, the field is now… at least twenty to thirty years behind the rest of child health.” Children, abusive parents and traumatized adults are unlikely to advocate for themselves like those with other diseases. Screening for ACEs will function to raise awareness of the impact of this condition among medical practitioners and stimulate more research.
- While in the abstract there may be a “risk…whether the respondents will be offended or upset by answering personal questions about ACEs or whether the ACE questionnaire will erode the trust between clinician and patient or parent,” the overwhelming experience of those of us in frontline medicine using ACEs is the gratitude patients often express for having the opportunity to open up for the first time about their experience and the new intimacy created in the doctor patient relationship. At Kaiser, the ACEs questions as part of a general health assessment produced no complaints when used over 400,000 times. In fact, one internist reported that initiating the use of the ACEs questionnaire in his practice cured his ‘burnout.’
- Considering that there are over 3 million cases of child abuse resulting in over 2000 child fatalities in the USA annually (about twice as many deaths as are caused by childhood cancer) physicians should be eager and feel an ethical imperative to use ACEs screening to intervene in current or ongoing CAN situations without being constrained due to “insufficient evidence (that ACEs screenings…have been proven to improve outcomes” in individual patients. As in other medical situations (e.g. infectious disease, epilepsy, dementia) case identification may be as significant in a public health context as knowledge of effective therapy for the individual. In addition, for all the reasons enumerated here and especially to create the opportunity to intervene to prevent harm to helpless children, rather than waiting for proven treatments, it remains important to continue and expand ACEs screening.
- There has been a chronic shortage of appropriate medical attention to the trauma of CAN. Krugman recently observed, “For more than fifty years, not enough has been done to tackle the national problems of child abuse and neglect….(This) gaze aversion…seems to be operative today in the paucity of research on the causes, treatment, and impact of all forms of child abuse and neglect on the health and well-being of children, adolescents, and adults….We need all Americans (and the health professionals who serve them) to view child abuse and neglect not just as a social and legal issue, buy as a health, mental health, and public health concern. We need to remove the shame and stigma that accompany the diagnosis.”
- There is no better way to start improving this situation that to promote ACEs screening at every clinical encounter.
Jeoffry B. Gordon, MD, MPH